Fundamental Concepts and Skills for Nursing Test Bank

Correct Answer: C

Rationale: For an older patient with heart failure prescribed digoxin (Lanoxin) 125 mcg by mouth three times a week, the nurse should administer the drug as prescribed while monitoring for manifestations of toxicity. Digoxin is a medication commonly used in heart failure, but it has a narrow therapeutic index, meaning that the difference between a therapeutic dose and a toxic dose is small. Older patients are more susceptible to digoxin toxicity due to age-related changes in pharmacokinetics and pharmacodynamics, as well as potential comorbidities. Therefore, close monitoring for signs and symptoms of digoxin toxicity, such as nausea, vomiting, visual disturbances, and cardiac arrhythmias, is essential. It is important for the nurse to be vigilant for any early signs of toxicity and communicate any concerns to the healthcare provider promptly.

Correct Answer: C

Rationale: The statement "If I take my medications as prescribed, I'll feel better" best illustrates compliance with the medication plan. This statement shows an understanding of the importance of following the prescribed medication regimen and the potential positive outcomes of adherence to the plan. It demonstrates the client's willingness to adhere to the instructions given by the nurse, which is essential for successful medication management and treatment outcomes.

Correct Answer: D

Rationale: Wheezing breath sounds in all lobes indicate airway obstruction or narrowing, which may be a sign of worsening heart failure leading to pulmonary congestion. Wheezing can be a result of fluid accumulation in the lungs (pulmonary edema) due to inadequate pumping of the heart in CHF. Monitoring for respiratory symptoms such as wheezing is crucial in assessing the effectiveness of treatment for congestive heart failure. In this case, the presence of wheezing suggests that the client's condition is not improving and requires further evaluation and intervention.

Correct Answer: B

Rationale: An increased amount of antidiuretic hormone (ADH) leads to the condition known as syndrome of inappropriate antidiuretic hormone (SIADH). This condition results in the kidneys absorbing more water, which leads to decreased urine output (oliguria) and concentrated urine. The increased ADH levels cause the body to retain fluid, leading to a decrease in urine output and potential complications such as hyponatremia (low sodium levels), which can be harmful. Increased facial hair growth or decreased testosterone production are not directly related to an overproduction of ADH.

Correct Answer: B

Rationale: Atorvastatin (Lipitor) is a medication commonly used to treat high cholesterol levels. One of the serious side effects associated with atorvastatin use is muscle pain and weakness. This could be a sign of a rare but serious condition known as rhabdomyolysis, which is the breakdown of muscle tissue that can lead to kidney damage. Therefore, it is crucial for the client to report any muscle pain or weakness promptly to their healthcare provider to prevent any serious complications. Headaches and nausea are common side effects that may not require urgent attention. Bruising and excessive bleeding usually indicate a different issue, such as a bleeding disorder or anticoagulant medication effect. Shortness of breath and coughing are not typically associated with atorvastatin use and may suggest other health problems that require evaluation by a healthcare provider.